Surgical Technique Is pars plana vitrectomy a safe method for performing fine needle aspiration biopsy of choroidal melanoma? What are the rates of complications? Clinical Characteristics Do tumor thickness and largest basal diameter correlate with class II designation? Introduction Patients with choroidal melanoma are at risk of metastasis and death despite local control of the tumor with radiation therapy. Genetic analysis of tumor cells allows for more accurate risk stratification and can be obtained via fine needle aspiration biopsy (FNAB). Extraocular spread following biopsy has been reported, albeit rarely. We describe our technique using a standard pars plana vitrectomy (PPV) approach and report the outcomes and surgical complications. Methods Study design: retrospective case series 16 patients, evaluated by an ocular oncologist (JSD), underwent PPV with biopsy of choroidal melanoma between December 2014 and December 2016 at the New England Eye Center, Boston, MA. Surgical technique: Three 25g trocars are placed in standard fashion with infusion. Following limited core PPV, a 27g needle attached to manual suction is passed through a trocar for FNAB under direct visualization, and repeated with new instrumentation. The samples are sent for cytopathology and gene expression profile (GEP; Castle Biosciences Inc., Phoenix, AZ). A partial air fluid exchange is performed to tamponade the biopsy site. Cryotherapy is not applied to the sclerotomy sites. Exclusion criteria Extraocular extension; biopsy via trans-sclera approach Transvitreal Fine Needle Aspiration Biopsy of Choroidal prognosticinformation,biopsywithgepanalysiscanimprovepost\ fortransvitrealfnabwithalowriskofcomplications,including 1 iatrogenicdissemination. Dept. of Ophthalmology, Lahey Hospital and Medical Canter, Burlington, MA 2 The Retina Institute, St. Louis, MO 3 New England Eye Center, Tufts Medical Center, Boston, MA Michael D. Lewen 1, MD; Sabin Dang 2, MD; Nora Laver 3, MD; Jay S. Duker 3, MD Purpose Mean Thickness 5.68 (range: 3.61-3.195 (range: 2.99-4.18 (range: 2.5- Conclusions Inthiscohort,Class1AtumorswereonaveragelargerthanClass2tumors Table 1: Patient Cohort Table 2: Tumor Characteristics Table 3: Surgical Characteristics Table+1:+ Radiation Treatment Complications There were no instances of rhegmatogenous retinal detachment, worsening of pre-existing subretinal fluid, endophthalmitis, or local spread of melanoma to the conjunctiva or orbit. Table 4: Tumor Characteristics by GEP Class Designation Mean Thickness a. Predictedmetastasis\freesurvivalatfiveyearsis98%,79%and28% forgepclasses1a,1band2,respectively(reference).withthis radiationcareforpatientsdiagnosedwithchoroidalmelanoma.in ourexperience,ppvsafelyaffordsoptimalvisualizationandcontrol Small (< 3.0 mm) 3 (18.75%) Thickness Medium (3.1 8.0 mm) 11 (68.75%) Large (> 8.0 mm) 2 (12.5%) Largest basal 5 16 mm 14 (87.5%) diameter 16 mm 2 (12.5%) Histopathology Predominantly epithelioid 2 (12.5%) Mixed spindle/epithelioid 8 (50%) Non-diagnostic/other 6 (37.5%) 1A 8 (50%) GEP Class 1B 2 (12.5%) 2 6 (37.5%) 5.68 (range: 3.61-3.195 (range: 2.99- Class 1A tumors were on average larger than class 2 tumors Plaque 13(81.25%) Gamma knife 2(12.5%) Proton beam 1(6.25%) Local vitreous 4(25%) Diffuse vitreous 1(6.25%) 4.18 (range: 2.5- Predicted metastasis-free survival at five years is 98%, 79% and 28% for GEP classes 1A, 1B, and 2, respectively (reference: Castle Biosciences Inc., Phoenix, AZ) Biopsy with GEP can improve post-radiation care for patients with choroidal melanoma with this prognostic data. In this cohort to date, metastasis has occurred in one patient, whose tumor was GEP class 2. In our experience, PPV affords optimal visualization and control for transvitreal FNAB with low risk of complications, including iatrogenic spread. Retrospective study Small sample size Limited follow-up Single surgeon Limitations References Damato B. Legacy of the collaborative ocular melanoma study. Arch Ophthalmol. 2007 Jul;125(7):966-8. Harbour JW. The genetics of uveal melanoma: an emerging framework for targeted therapy. Pigment cell melanoma res. 2012 March; 25(2): 171-181 Onken MD, Worley LA, Char DH, Augsburger JJ, et al. Collaborative Ocular Oncology Group report number 1: prospective validation of a multi-gene prognostic assay in uveal melanoma. Ophthalmology. 2012 Aug;119(8):1596-603 Onken MD, Worley LA, Ehlers JP, Harbour JW. Gene expression profiling in uveal melanoma reveals two molecular classes and predicts metastatic death. Cancer Res. 2004 Oct 15;64(20):7205-9. Schefler AC, Gologorsky D, Marr BP, Shields CL, et al. Extraocular extension of uveal melanoma after fine-needle aspiration, vitrectomy, and open biopsy. JAMA Ophthalmol. 2013 Sep;131(9):1220-4. doi: 10.1001/jamaophthalmol.2013.2506. Mashayekhi A, Lim RP, Shields CL, Eagle RC Jr, Shields JA. Extraocular extension of ciliochoroidal melanoma after transscleral fine needle aspiration biopsy. Retinal Cases and Brief Reports. 10:289-292, 2016. None (All Authors) Disclosures
Methods Study design: retrospective case series 16 patients, evaluated by an ocular oncologist (JSD), underwent PPV with biopsy of choroidal melanoma between December 2014 and December 2016 at the New England Eye Center, Boston, MA. Surgical technique: Three 25g trocars are placed in standard fashion with infusion. Following limited core PPV, a 27g needle attached to manual suction is passed through a trocar for FNAB under direct visualization, and repeated with new instrumentation. The samples are sent for cytopathology and gene expression profile (GEP; Catsle Biosciences Inc., Phoenix, AZ). A partial air fluid exchange is performed to tamponade the biopsy site. Cryotherapy is not applied to the sclerotomy sites. Exclusion criteria Extraocular extension; biopsy via trans-sclera approach
Table 1: Patient Cohort Table 2: Tumor Characteristics Small (< 3.0 mm) 3 (18.75%) Thickness Medium (3.1 8.0 mm) 11 (68.75%) Large (> 8.0 mm) 2 (12.5%) Largest basal diameter 5 16 mm 14 (87.5%) 16 mm 2 (12.5%) Histopathology Predominantly epithelioid 2 (12.5%) Mixed spindle/epithelioid 8 (50%) Non-diagnostic/other 6 (37.5%) 1A 8 (50%) GEP Class 1B 2 (12.5%) 2 6 (37.5%)
Table 3: Surgical Characteristics Radiation Treatment Plaque 13(81.25%) Gamma knife 2(12.5%) Proton beam 1(6.25%) Complications Local vitreous Diffuse vitreous 4(25%) 1(6.25%) There were no instances of rhegmatogenous retinal detachment, worsening of pre-existing subretinal fluid, endophthalmitis, or local spread of melanoma to the conjunctiva or orbit. Table 4: Tumor Characteristics by GEP Class Designation Mean Thickness 5.68 (range: 3.61-3.195 (range: 2.99-4.18 (range: 2.5- Class 1A tumors were on average larger than class 2 tumors
Conclusions A Predicted metastasis-free survival at five years is 98%, 79% and 28% for GEP classes 1A, 1B, and 2, respectively (reference: Castle Biosciences Inc., Phoenix, AZ). Biopsy with GEP can improve post-radiation care for patients with choroidal melanoma with this prognostic data. In this cohort to date, metastasis has occurred in one patient, whose tumor was GEP class 2. In our experience, PPV affords optimal visualization and control for transvitreal FNAB with low risk of complications, including iatrogenic spread.